Posts tagged with "stress incontinence"

What is urinary incontinence (UI) in women?

Urinary incontinence is the loss of bladder control, resulting in the accidental loss of urine. Some women may lose urine while running or coughing, called stress incontinence. Others may feel a strong, sudden need, or urgency, to urinate just before losing urine, called urgency incontinence. Many women experience both symptoms, called mixed incontinence, or have outside factors, such as difficulty getting to a standing position or only being able to walk slowly, that prevent them from getting to a toilet on time.

UI can be slightly bothersome or totally debilitating. For some women, the chance of embarrassment keeps them from enjoying many physical activities, including exercising. People who are inactive are more likely to be obese. Obesity increases a person’s chances of developing diabetes and other related health problems. UI can also cause emotional distress. However, UI often can be controlled.

What is the urinary tract and how does it work?

The urinary tract is the body’s drainage system for removing urine, which is composed of wastes and extra fluid. For normal urination to occur, all body parts in the urinary tract need to work together in the correct order.

Kidneys. The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine. The kidneys work around the clock; a person does not control what they do.

Ureters. Ureters are the thin tubes of muscle that carry urine from each of the kidneys to the bladder.

Bladder. The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Although a person does not control kidney function, a person does control when the bladder empties. Bladder emptying is known as urination. The bladder stores urine until the person finds an appropriate time and place to urinate. A normal bladder acts like a reservoir and can hold 1.5 to 2 cups of urine. How often a person needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. The muscles of the bladder wall remain relaxed while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon. During urination, the bladder empties through the urethra, located at the bottom of the bladder.

Three sets of muscles work together like a dam, keeping urine in the bladder between trips to the bathroom.

The first set of muscles, called the internal sphincter, is located where the bladder neck joins the urethra and along the urethra itself. The second set of muscles, along the outside of the urethra, is the external sphincter. The third set are the pelvic floor muscles, which surround and support the urethra. The pelvic floor muscles run between the pubic bone to the tail bone.

To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.

What causes urinary incontinence in women?

Urinary incontinence in women results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

What are the types of urinary incontinence in women?

The types of UI in women include

stress incontinence

urgency incontinence

mixed incontinence

other types of incontinence

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. Physical changes from pregnancy and childbirth often cause stress incontinence. Weakening of pelvic floor muscles can cause the bladder to move downward, pushing the bladder slightly out of the bottom of the pelvis and making it difficult for the sphincters to squeeze tightly enough. As a result, urine can leak during moments of physical stress. Stress incontinence can also occur without the bladder moving downward if the urethra wall is weak. This type of incontinence is common in women, and a health care professional can treat the condition.

Urgency Incontinence

Urgency incontinence is the loss of urine when a woman has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for women with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

Damage to the spinal cord or brain, the bladder nerves, or the bladder muscles may cause involuntary bladder contractions. Bladder nerves and muscles can be affected by

Alzheimer’s disease—a brain disorder that affects the parts of the brain that control thought, memory, and language

injury

multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and body

Parkinson’s disease—a disease in which cells that make a chemical that controls muscle movement are damaged or destroyed

stroke—a condition in which the blood supply to the brain is suddenly cut off, caused by a blockage or the bursting of a blood vessel in the brain or neck

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Mixed Incontinence

Mixed incontinence is when stress and urgency incontinence occur together.

Other Types of Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a toilet in time. For example, a woman with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A woman in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a woman to walk to the toilet quickly or unbutton her pants in time.

Transient incontinence is UI that lasts a short time. Transient incontinence is usually caused by medications or a temporary condition, such as

caffeine or alcohol consumption—consumption of caffeine or alcohol can cause rapid filling of the bladder

chronic coughing—chronic coughing can put pressure on the bladder

constipation—hard stool in the rectum can put pressure on the bladder

medication—blood pressure medications can cause increased production of urine

short-term mental impairment

short-term restricted mobility

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. A health care professional can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a toilet in time.

How common is urinary incontinence in women?

Research shows that 25 to 45 percent of women have some degree of UI. In women ages 20 to 39, 7 to 37 percent report some degree of UI. Nine to 39 percent of women older than 60 report daily UI. Women experience UI twice as often as men.1 Pregnancy, childbirth, menopause, and the structure of the female urinary tract account for this difference.

How is urinary incontinence in women diagnosed?

Women should let their health care provider, such as a family practice physician, a nurse, an internist, a gynecologist, urologist, or a urogynecologist—a gynecology doctor who has extra training in bladder problems and pelvic problems in women—know they have UI, even if they feel embarrassed. To diagnose UI, a health care professional will take a medical history and conduct a physical exam. The health care professional may order diagnostic tests, such as a urinalysis.

Medical History

The health care professional will take a medical history and ask about symptoms, patterns of urination and urine leakage, bowel function, medications, history of childbirth, and past pelvic operations. To prepare for the visit with the health care professional, a woman may want to keep a bladder diary for several days beforehand. Information that a woman should record in a bladder diary includes

what and how much she drinks

how many times she urinates and how much urine is released

how often she has accidental leaks

whether she feels a strong urge to go before leaking

what she was doing when leaks occurred, for example, coughing or lifting

Physical Exam

The health care professional will also perform a limited physical exam to look for signs of medical conditions that may cause UI. The health care professional may order further neurologic testing if necessary. The health care professional may also perform pelvic and rectal exams.

Pelvic exam. A pelvic exam is a visual and physical exam of the pelvic organs. The health care professional has the woman come to the exam with a full bladder. The woman will sit upright with her legs spread and asks her to cough. This test is called a cough stress test. Leakage of urine indicates stress incontinence. The health care professional then has the woman lie on her back on an exam table and place her feet on the corners of the table or in supports. The health care professional looks at the pelvic organs and slides a gloved, lubricated finger into the vagina to check for prolapse or other physical problems that may be causing UI. The health care professional will determine the woman’s pelvic muscle strength by asking her to squeeze her pelvic floor muscles.

Digital rectal exam. A digital rectal exam is a physical exam of the rectum. The health care professional slides a gloved, lubricated finger into the rectum, usually during a pelvic exam. A health care professional uses the digital rectal exam to check for stool or masses in the rectum that may be causing UI.

The health care professional may diagnose the type of UI based on the medical history and physical exam or use this information to determine if a woman needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or both of the following diagnostic tests, based on the results of the medical history and physical exam:

Urinalysis. Urinalysis is testing of a urine sample. The patient collects the urine sample in a special container in a health care professional’s office or a commercial facility for testing and analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present in urine. A person does not need anesthesia for this test. The test can show if the woman has a UTI, a kidney problem, or diabetes.

Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A woman collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the woman has a UTI. More information is provided in the NIDDK health topic, Urinary Tract Infection in Adults.

Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show problems with kidney function or a chemical imbalance in the body.

Urodynamic testing. Urodynamic testing is any procedure that looks at how well the bladder, urethra, and sphincters store and release urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely. More information is provided in the NIDDK health topic, Urodynamic Testing.

How is urinary incontinence in women treated?

Treatment depends on the type of UI. Health care professionals may recommend behavioral and lifestyle changes, stopping smoking, bladder training, pelvic floor exercises, and urgency suppression as a first-line therapy for most types of UI.

Stress Incontinence

Behavioral and lifestyle changes. Women with UI may be able to reduce leaks by making behavioral and lifestyle changes. For example, the amount and type of liquid women drink can affect UI. Women should talk with their health care professional about whether to drink less liquid during the day; however, women should not limit liquids to the point of becoming dehydrated. Signs of dehydration in women include

constipation

dark-colored urine

dizziness

dry skin

fatigue, or feeling tired

less frequent urination than usual

light-headedness

thirst

A health care professional can help a woman determine how much she should drink to prevent dehydration based on her health, how active she is, and where she lives.

To decrease nighttime trips to the bathroom, women may want to stop drinking liquids several hours before bedtime if suggested by a health care professional. Limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—may decrease leaks. Women should also limit alcoholic drinks, which can increase urine production.

Although a woman may be reluctant to engage in physical activity when she has UI, regular exercise is important for weight management and good overall health. Losing weight may improve UI and not gaining weight may prevent UI. If a woman is concerned about not having easy access to a bathroom during physical activity, she can walk indoors, like in a mall, for example. Women who are overweight should talk with their health care professional about strategies for losing weight. Being obese increases a person’s chances of developing UI and other diseases, such as diabetes. According to one study, decreasing obesity and diabetes may lessen the burden of UI, especially in women.2 More information is provided in the NIDDK health topics, Choosing a Safe and Successful Weight-loss Program and Tips to Help You Get Active.

Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to UI. The opposite is also true: Urinary problems such as UI can make GI problems worse. For example, medications such as antimuscarinics, which health care professionals use to treat UI, have side effects such as constipation.

Health care professionals can offer several options for treating constipation. More information is provided in the NIDDK health topic, Constipation.

Although a woman may be reluctant to engage in physical activity when she has UI, regular exercise is important for weight management and good overall health.

Stopping Smoking. People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chances of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time.3 People who smoke should ask for help so they do not have to try quitting alone. Call 1–800–QUITNOW (1–800–784–8669) for more information.

Bladder training. Bladder training is changing urination habits to decrease incidents of UI. Based on a woman’s bladder diary, the health care professional may suggest using the bathroom at regular timed intervals, called timed voiding. Gradually lengthening the time between trips to the bathroom can help by stretching the bladder so it can hold more urine. Recording daily bathroom habits may be helpful. More information is provided in the NIDDK health document, Daily Bladder Diary(PDF, 80 KB).

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold in urine than weak muscles. A woman does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination. A health care professional can help a woman learn proper technique. More information is provided in the NIDDK health topic, Kegel Exercise Tips.

Women may also learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video screen displays the measurements as graphs, and sounds indicate when the woman is using the correct muscles. The health care professional uses the information to help the woman change abnormal function of the pelvic floor muscles. At home, the woman practices to improve muscle function. The woman can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of UI, its severity, and the woman’s ability to perform the exercises on a regular basis.

If behavioral and lifestyle changes, stopping smoking, bladder training, and pelvic floor muscle exercises are not successful, additional measures for stress incontinence, including medical devices, bulking agents, and—as a last resort—surgery, may help.

Medical devices. A health care professional may prescribe a urethral insert or pessary to treat stress incontinence. A urethral insert is a small, tamponlike, disposable device inserted into the urethra to prevent leakage. A woman may use the insert to prevent UI during a specific activity or wear it throughout the day. The woman removes the insert to urinate. A pessary is a stiff ring inserted into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less leakage. The woman should remove the pessary regularly for cleaning.

Bulking agents. A doctor injects bulking agents, such as collagen and carbon beads, near the urinary sphincter to treat urgency and stress incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, a health care professional may perform a skin test to make sure the woman doesn’t have an allergic reaction to the bulking agent. A doctor performs the procedure during an office visit. The woman receives local anesthesia. The doctor uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a woman may need to have injections again. The treatment is effective in about 40 percent of cases.4

Surgery. The bladder neck dropping toward the vagina can cause incontinence problems. Surgery to treat stress incontinence includes retropubic suspension and sling procedures. A doctor performs the operations in a hospital. The patient receives general anesthesia. Most women can leave the hospital the same day, though some may need to stay overnight. Full recovery takes 2 to 3 weeks; women who also have surgery for pelvic organ prolapse at the same time may have a longer recovery time.

Retropubic suspension. With retropubic suspension, the doctor raises the bladder neck or urethra and supports it using surgical threads called sutures. The doctor makes an incision in the area between the chest and the hips—also called the abdomen—a few inches below the navel and secures the sutures to strong ligaments within the pelvis to support the urethral sphincter.

Sling. The doctor performs sling procedures through a vaginal incision and uses natural tissue, man-made sling material, or synthetic mesh tape to cradle the bladder neck or urethra, depending on the type of sling procedure being performed. The doctor attaches the sling to the pubic bone or pulls the sling through an incision behind the pubic bone or beside the vaginal opening and secures it with stitches.

The Urinary Incontinence Treatment Network compared the suspension and sling procedures and found that according to women’s bladder diaries, about 31 percent with a sling and 24 percent with a suspension were still continent, or able to hold urine, all of the time 5 years after surgery. However, 73 percent of women in the suspension group and 83 percent of women in the sling group said they were satisfied with their results. Rates of adverse events such as UTIs and UI were similar for the two groups, at 10 percent for the suspension group and 9 percent for the sling group.5

Serious complications are associated with the use of surgical mesh to repair incontinence. Possible complications include erosion through the lining of the vagina, infection, pain, urinary problems, and recurrence of incontinence.6

Each woman should speak to her health care professional to help decide which surgery, if any, is right for her.

Urgency Incontinence

Women who have urgency incontinence can use the same techniques as for stress incontinence, including bladder training, urgency suppression, pelvic floor exercises, and behavioral and lifestyle changes. A woman can also try urgency suppression techniques, medications, Botox injections, and electrical nerve stimulation if necessary.

Urgency suppression. By using certain techniques, a woman can suppress the strong urge to urinate, called urgency suppression. Urgency suppression is a way to train the bladder to maintain control so a woman does not have to panic about finding a bathroom in the meantime. Some women use distraction techniques to take their mind off the urge to urinate. Other women find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urgency to urinate.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), which a person can buy over the counter, tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Botox. A doctor may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urgency incontinence in women including those with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing UI. A doctor often performs the procedure during an office visit. A woman receives local anesthesia. The doctor uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.7

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent UI, urinary frequency—urinating more than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation.8

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. Anesthesia is not normally needed for the procedure. In an outpatient center, a health care professional inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although percutaneous tibial nerve stimulation is considered safe, researchers continue to study the exact ways it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves a health care professional implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center often with local anesthesia. Based on the person’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair—or through special devices inserted into the vagina. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The person can turn the stimulator on or off at any time. If a period of test stimulation is successful, a health care professional will implant a device that delivers regular impulses to the bladder. A health care professional places a wire next to the tailbone and attaches it to a permanent stimulator under the skin of the lower abdomen.

If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent UI, urinary frequency, and other symptoms.

Mixed Incontinence

Depending on the type of symptoms a woman has, she may successfully treat her mixed incontinence with techniques, medications, devices, or surgery. A health care professional can help decide what kind of treatments may work for each symptom.

Functional Incontinence

Women with functional incontinence may wear protective undergarments if they worry about reaching a toilet in time. Women who have functional incontinence should talk to their health care professional about its causes and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Women with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a woman how to use a catheter. A woman may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the woman’s thigh with a strap. Women using a continuous, often called indwelling, catheter should watch for symptoms of a urinary tract infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to UI, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat UTIs.

How can someone cope with leaking urine?

Even after treatment, some women still leak urine from time to time. Certain products can help women cope with leaking urine:

Pads. Women can wear disposable pads in their underwear to absorb leaking urine.

Adult diapers. A woman can wear an adult diaper to keep her clothes dry.

Disposable pads. Disposable pads can be used to protect chairs and beds from urine.

Special skin cleaners and creams. Special skin cleaners and creams may help the skin around the urethra from becoming irritated. Creams can help block urine from skin.

Urine deodorizing tablets. A woman should talk with a health care professional about whether urine deodorizing tablets can make her urine smell less strongly.

Eating, Diet, and Nutrition

No direct scientific evidence links eating, diet, and nutrition to either improving or worsening UI. However, many people find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation, which can sometimes lead to UI.9 Moreover, good eating, diet, and nutrition are directly related to preventing factors that increase the chances of developing UI, such as obesity and diabetes.

Points to Remember

Urinary incontinence (UI) is the loss of bladder control, resulting in the accidental loss of urine.

The urinary tract is the body’s drainage system for removing urine, which is composed of wastes and extra fluid.

Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine.

To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax. As the sphincters relax, urine exits the bladder through the urethra.

UI in women results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both.

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity.

Physical changes from pregnancy and childbirth often cause stress incontinence.

Urgency incontinence is the loss of urine when a woman has a strong desire, or urgency, to urinate.

[3] National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. What You Need to Know About Bladder Cancer. Rockville, MD: National Cancer Institute; 2010. NIH Publication No.10-1559.